India: 'Abortion access- essential on paper, inaccessible in reality' with Shwetangi Shinde
Updated: May 21
Shwetangi Shinde from Mumbai, India is a doctor currently on the frontline fighting COVID19, a Youth Champion alumni and core team member of India Safe Abortion Youth Advocates. She took out some time from her busy schedule and spoke to us about access to abortion and shared stories of many other challenges faced by womxn, especially with the added stigma of Covid19 .
Image source - The Week
ASAP: Has abortion been declared an essential service in India yet? If yes, how easy or difficult will it be for people to access abortion during the lockdown?
Shwetangi: The Ministry of Health and Family Welfare has listed abortion services within the essential services that need to continue to be provided during the lockdown. While this is a positive step, the reality is, as always, very different. Abortion access has been difficult in India even at the best of times. The lack of awareness of the legal status of abortion, lack of ability to negotiate these decisions with husband and family members, lack of physical and financial access, insensitive attitudes of healthcare providers have been reported in study after study down the years. What the current pandemic has done is exacerbated all these and more in ways that are making access almost impossible.
ASAP: You along, with some other Youth Champions from India are currently on the frontline, so what have been your observations and experience?
Shwetangi: Some instances have definitely come up worth mentioning in Mumbai, which entered the 28th day of lockdown today ● Delayed presentation – More than one woman has come in 2 weeks after they decided to have an abortion (delayed pregnancy confirmation because they could not get the kits, they had no transport, they did not know if abortion is being provided as an essential service,). However, due to that delay, they were now over 10 weeks and medical abortion was no longer an option. Surgical abortion was provided to both.
● Lack of correct information - About how to access healthcare during lockdown. There is no common list of hospitals or directory that can help guide them about where they can go to for pregnancy testing, abortion, deliveries, contraception. Friends working with helplines are reporting an enormous increase in the number of calls just asking about MA or simply – ‘How do I get an abortion?’
● Lack of transport – One patient told us about a police officer who beat her husband up because he was not ready to accept that the woman was pregnant – “because there wasn’t an obvious bump”. He also refused to let them get into a cab/bus because he thought they were lying about wanting to go to the hospital. Three days after this happened, they managed to get hold of an ambulance and that's how they came to the hospital. ● Telemedicine -- Even though it has been made legal, there has to be more clarity given to the general population on how to use it. We haven’t come across anyone addressing the importance of Telemedicine with respect to abortion access in a national capacity – like they have declared it an essential service but there is no information anywhere on how to access abortion services. (eg. The UK has started – ‘pills by post’ after online consultation, they are delivering MA pills to people who don’t need to be referred)
● MA pills – Some people have reported difficulty finding MA pills even with a prescription, but maybe it was specific to that area. We do not have any information on the availability of pills is in general. Since the public sector hospitals do not provide it on indent (despite approval to do so many years ago) people will have to depend on retail supplies and prescriptions.
Since most of the abortions take place outside of public healthcare facilities, and with most private clinics being shut, we are expecting to see a spurt in the number of unsafe abortions this month. ● COVID fear – At the ObGyn department it has been noticed that the Ante Natal Care registration rate has come down and it is definitely not because people aren’t getting pregnant anymore. There is this weird fear and/or stigma that is being associated with COVID, some real terror of having to live away from your family, in case you get tested positive as a result of which less people are coming to the hospital, which is great with respect to #SocialDistancing but not so great if they aren’t communicating with a Doctor or visiting some nearest sub-centre for healthcare they actually need!
● HIV testing – There is a huge scarcity of testing kits for HIV primarily due to lack of transport and also, due to diversion of many manufacturing units to production of testing kits for COVID. There's also an issue with relatives of patients not being allowed to the ART centers to collect their medicines and a lot of HIV positive individuals are finding it difficult to have continuous access to ART meds.
● Domestic violence –We are observing two kinds of patterns here. One is where men who were regular alcohol consumers and used to beat their wives under the influence of alcohol have stopped because there's no alcohol being sold upfront and there's no money to buy it since most of these people are daily wage workers/house help. But the downside to the lockdown is that women are now confined to their homes, and are finding it very difficult to get any kind of external help or somehow escape domestic violence/ forced sex because their partners are getting to dictate and control their actions completely. The decreased/no access to emergency contraception cuts off even the last hope for avoiding an unwanted pregnancy.
ASAP: Can you elaborate on how these challenges have emerged because of the pandemic?
Shwetangi: While all this is related to the current acute crisis caused by Covid19 and our responses to the pandemic, this is happening against a background of long standing deprivations and structural violations and violence that women have been facing for generations.
Here is a case we saw the other day - A 28 years old woman, pregnant for the 8th time. The relatives kept saying she got married at 19, but we suspect it was much earlier because8 pregnancies in 9 years is impossible to fathom it's like she literally moved from one pregnancy into another. So, 5 months ago, she missed her period, did a urine pregnancy test that was positive and she went to a 'doctor' (she was unable to share any documentation/ case paper) who gave her an abortifacient. She consumed it and the usual bleeding and cramping began after 24 hours. She had no follow up with this alleged 'doctor' but when she repeated the pregnancy test it was negative, so she assumed that the abortion happened. Then she went to some other 'doctor' and got an IUD inserted and now she's moved on with her life. Again, there's absolutely no documentation at all of any of these interventions. Now she has come to us at the hospital with bleeding so given the history we did an ultrasound scan and realized that there is still a live fetus and the IUD has gone deeper into her uterus. So we had to do a hysterectomy since she was likely to develop sepsis otherwise. When we tried talking to her alone, that woman confessed that she was being forced into having kids - there was some kind of trend in the area that she came from where they would judge the sexual prowess of a man by the number of kids that they produce. We encouraged her to file a police complaint gave her a social worker reference but she was so scared of even talking to us that day that her future does not look very bright to us.
It is a tragedy of ridiculous proportions that women in a city like Mumbai are still struggling with such issues which we had hoped to leave behind in the dark pages of history many centuries ago. For us as healthcare workers on the frontline the current pandemic is taking up all our energies and our attention but cases like this stay with us and make us wonder if the post pandemic world would be any better for them?